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Anaesthesia for Trauma. C Berger MD FRCP(C) For NMH residents, Kabul. Anaesthesia for Trauma. Conduct of anaesthesia requires awareness of all sustained injuries. In the initial resuscitation – focus on airway, c-spine, and cardiothoracic injuries

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Anaesthesia for Trauma

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Anaesthesia for trauma

Anaesthesia for Trauma

C Berger MD FRCP(C)

For NMH residents, Kabul

Anaesthesia for trauma1

Anaesthesia for Trauma

  • Conduct of anaesthesia requires awareness of all sustained injuries. In the initial resuscitation – focus on airway, c-spine, and cardiothoracic injuries

  • If time permits – review with trauma team leader or perform your own ABCDE assessment

  • Initial trauma protocol –

    • O2

    • 2 large bore IV’s

    • Investigations – CBC, cross match, lytes, Coags, ABG

      Others according to history / physical exam

    • Consider – CXR, C-spine, Pelvic imaging

Anaesthesia for trauma2

Anaesthesia for Trauma

  • If situation does not permit full assessment :

    • Obtain AMPLE history

    • A – Allergies

    • M – Medications

    • P – Past medical history

    • L – Last meal

    • E – Events leading to injury

      And proceed with interventions

Anaesthesia for trauma3

Anaesthesia for Trauma

  • Keep in mind – 6 injuries that kill quickly

    • these need to be identified and treated during primary survey

      • Airway obstruction

      • Open pneumothorax

      • Tension pneumothorax

      • Flail chest with pulmonary contusion

      • Massive hemothorax

      • Cardiac tamponade

Anaesthesia for trauma4

Anaesthesia for Trauma

  • Other life-threatening injuries :

    • Simple pneumothorax

    • Pulmonary contusion

    • Cardiac contusion

    • Aortic disruption

    • Diaphragmatic disruption

    • Tracheo-bronchial disruption

    • Esophageal disruption

Anaesthesia for trauma5

Anaesthesia for Trauma

  • Airway Control : requires ETT, stylet, bougie, suction, O2 (Ambu bag ), LMA, and Cricothyroidotomy kit at the ready

  • Consider :

    • Full stomach

    • Potentially difficult ( blood, cervical collar )

    • C-spine injury requiring in line stabilization

    • Pneumothorax requiring decompression

    • Closed head injury requiring adequate perfusion pressure

    • Open eye injury to prevent vitreal extrusion

    • Hemodynamic situation

    • Beware nasal intubation in facial injuries

Anaesthesia for trauma6

Anaesthesia for Trauma

  • Airway

    • pre-oxygenate

    • in line cervical stabilization, cricoid pressure

    • Administer drugs

      • Attempt DL

      • 2nd attempt DL +/- appropriate airway adjuncts

      • LMA

        if all above unsuccessful

      • Emergency cricothyroidotomy

      • Definitive controlled tracheostomy

  • Ventilation

    • no benefit to supra-normal FiO2

    • Normocarbia in absence of closed head injury or compensating for severe metabolic acidosis

  • Anaesthesia for trauma

    Hangman Fracture Jefferson Fracture

    C2 pedicle MVA C1 burst – axial loading

    Anaesthesia for trauma7

    Anaesthesia for Trauma

    Circulation – class 3-4 shock will likely require massive transfusion

    • Initial Hgb < 100, ph <7.15, Coagulopathy all indicators of massive blood loss

    • IV fluids to be warmed

    • After initial bolus give crystalloid judiciously

    • Blood products – give as soon as the necessity is recognized

    • Depending on blood bank – MT protocols save lives !

      • Type specific whole blood ( fresh blood richer in procoagulants )

      • Packed cells, Plasma, Platelets in equal ratios for MT ( 1:1:1 )

      • Tranexamic acid within first two hours

    • Colloids controversial and no better than crystalloid

      • Beware the terrible triad ; treat aggressively

        HypothermisCoagulopathy Acidosis

    Anaesthesia for trauma8

    Anaesthesia for Trauma

    • Acidosis– usually due to low perfusion and lactate production

      • impaired myocardial function and response to catecholamines

      • Wosens coagulopathy

    • Coagulapathy – may be worsened by large volume crystalloids (dilution of pro-coagulants ) and artificial colloids

      ( reduced platelet adherence )

    • Hypothermia – contributes to coagulopathy

      • Worsens muscular ( cardiac ) function

      • Reduces platelet adhesion

      • Warm all fluids, OR, Bair hugger, irrigation

      • Linear relationship between extent of hypothermia and mortality

    Anaesthesia for trauma9

    Anaesthesia for Trauma

    • Initial Surgery

      • Life saving interventions only

      • Damage Control Surgery

      • Ongoing physiological, hemostatic resuscitation

      • Do not over – resuscitate – permissive hypotension

        • Normal or supranormal BP may dislodge clot

        • Exception – closed head injury requires adequate CPP

      • Continue resuscitation in ICU

      • Supplemtal surgeries as required

        • packing change, debridements, washouts, re-anastamosis

    Anaesthesia for trauma10

    Anaesthesia for Trauma

    • Useful Drugs in Trauma :

      • None – consider in moribund patient, add as tolerated

      • Ketamine – indirect alpha and beta sympathomimetic

        • Direct negative inotrope – careful in moribund patients

        • Most recent studies suggest it is safe in CHI patients

      • Volatile Anaesthetics – use sub MAC doses and titrate carefully

        • Best to avoid N2O for closed space reasons

      • Rocuronium – alternative to succ

        • 1mg/Kg to decrease onset time

      • Vasopressors – as temporizing agents to support BP

      • Succinylcholine – usual contraindications apply

        • Safe in sc injury and major burns in first 24 hrs

    Anaesthesia for thoracic trauma

    Anaesthesia for Thoracic Trauma

    • Less than10% of blunt and 20% of penetrating trauma require thoracotomy

    • Indications :

      • Persistent Haemothorax

      • Persistent large air leak

      • Tracheo-bronchial disruption

      • Diaphragmatic disruption

      • Esophageal disruption

      • Cardiac Tamponade

      • Aortic disrution

    Anaesthesia for thoracic trauma1

    Anaesthesia for Thoracic Trauma

    • Hemothorax

      • Thoracotomy usually indicated for massive haemothorax ( > 1500cc ) or on-going blood loss

        ( > 200cc/hr x 2-4 hrs )

      • Large volume transfusion likely required

      • Consider DLT for large air leak or significant haemoptysis

    Anaesthesia for thoracic trauma2

    Anaesthesia for Thoracic Trauma

    • Tracheo-bronchial Disruption

      • Upper – bronchoscopic evaluation (SV) with placement of ETT below lesion. If very high then tracheostomy

      • Lower lesion – DLT

    • Esophageal Disruption

      • High mortality due to mediastnitis, empyema, sepsis

      • DLT for surgical exposure

    Anaesthesia for thoracic trauma3

    Anaesthesia for Thoracic Trauma

    • Aortic Disruption

      • Devastating hemorrhage – only 15% reach hospital alive

      • Always consider in high rib fractures

      • Massive transfusion, high incidence of associated thoracic injuries

      • Cosider cardiopulmonary bypass

    • Diaphragmatic Disruption

      • NGT to decompress stomach

      • DLT ( if possible ) improves surgical exposur

    Anaesthesia for thoracic trauma4

    Anaesthesia for Thoracic Trauma

    • Cardiac Tamponade

      • Consider in trauma patient ( usually penetrating ) who is not responding to fluids

      • Kussmal’s sign, Becks Triad, pulsus paradoxus

      • US is the best diagnostic tool and can assist in drainage

      • Induction of GA may be deadly – invasive pressures, maintain high CVP, high HR. consider epi infusion, ketamine induction and maintenane of spontaneous ventilation ( improve venous return )

      • Subxyphoid or intercostal incision

    Anaesthesia for trauma


    Acute cases will be

    more easily identified

    by US

    Anaesthesia for abdominal trauma

    Anaesthesia for Abdominal Trauma

    • For haemorrhage or organ injury

    • Bleeding can be extensive if major vascular of liver injury

    • Damage control surgery only

    • May need to pack and return later

    • Consider leaving abdomen open to avoid abdominal compartment syndrome after large volume resuscitation

    • Vac dressing

    Vac vacuum dressing

    VAC ( vacuum ) Dressing

    Anaesthesia for orthopaedic trauma

    Anaesthesia for Orthopaedic Trauma

    • Multiple sites may be involved

    • Large bone fractures may lose 500-1L blood

    • Functional examination pre-op important

    • Careful with patient positioning

    • Be aware of ischemic times ( tourniquet )

    • Monitor for rhabdomyolysis ( crush, compartment syndromes)

      and weigh safety of succ

    • Stabilization only ( X –fix ) and leave ( damage control )

    • Prophylactic fasciotomy

    • Fat Embolism ( hypoxemia, petechial rash, cerebral dysfunction )

    Anaesthesia for closed head trauma

    Anaesthesia for Closed Head Trauma

    • Head injury often associated with other ( C-spine ) injuries

    • High speed MVA, increased age, fall > 2m, intoxication

    • Ensure ABCD survey complete

    • GCS < 8, or decrease of 2 signal need for airway protection

    • In absence of other injuries, hemodynamics normal until late

    • Consider limited crystalloids, ? Hypertonic saline

    • Maintenance of Cerebral Perfusion Pressure is paramount

    • Avoid hypoxia, hyperglycemia, hypercarbia

    Anaesthesia for closed head trauma1

    The Cranial Vault is a closed space

    Occupants :

    Blood 10%

    Brain 80%

    CSF 10%

    Limited capacity to compensate for additional volume

    As compensatory mechanisms are exhausted, ICP increases, and CBF falls resulting in :

    Brain ischemia

    Anatomical shifts (herniation)

    Anaesthesia for Closed Head Trauma

    Anaesthesia for closed head trauma2

    Anaesthesia for Closed Head Trauma

    Anaesthesia for closed head trauma3

    Manipulate CBF and hence ICP

    Maintain O2, CPP

    CPP = MAP – ICP

    Reduced cerebral DO2 obviously deleterious

    PCO2 can be manipulated as a temporary measure to reduce ICP ( 30 -35 mmHg ; 4- 4.6 kpa )

    Prolonged or severe hypocarbia may worsen cerebral ischemia

    Anaesthesia for Closed Head Trauma

    Anaesthesia for closed head trauma4

    Anaesthesia for Closed Head Trauma

    • Permissive hypotension used in damage control surgery may not be appropriate in patients with closed head injury

    • Some cooling may be permissible and protective ( > 35* )

    • Elevate head of bed slightly if tolerated

    • Barituates, propofol infusion decrease cerebral mVO2

    • Other adjuncts ( mannitol, steroids ) not so useful in trauma

    • Discuss with neurosurgeon

    Anaesthesia for trauma11

    Anaesthesia for Trauma

    • In Conclusion :

      • Initial approach to all trauma patients is the same

      • ABC and treat immediate life threatening injuries

      • Gather information and know your patient

      • Avoid/treat aggressively the terrible triad

      • Conflicting goals may occur –

        • When in doubt recall the priorities of :

          A before B before C before D

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